Equine Health Certificate

Owner's name *

Your answer

Date of Travel *

YYYY

Owner's Address Street City State zip *

Your answer

Owner's cell phone *

Your answer

Owner's email *

Your answer

Is Address of Origin same as owner's address ? *

Yes

If not, Address of Origin (street, city, state, zip)

Your answer

Is Consignee same as owner (person accepting horse at destination address)? *

Yes

Consignee Name (if different than owner)

Your answer

Consignee Address (street, city, state, zip)

Your answer

Destination Address (street, city, state, zip) *

Your answer

Is Carrier same as owner *

Yes

If not, Carrier Name

Your answer

Carrier Address (Street, city, state, zip)

Your answer

Carrier phone number

Your answer

Horse's name *

Your answer

Age *

Your answer

Height *

Your answer

Color *

Your answer

Breed *

Your answer

Sex *

Mare

Gelding

Stallion

Filly

Colt

Brand and/or Tatoo ?

Your answer

Microchip Number

Your answer

Do you have a current coggins ? *

Yes

Lab name *

Your answer

Accession number *

Your answer

Date of Negative Result *

YYYY

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This form was created inside of 5 Elements for Animals.